What is body dysmorphic disorder?

The quest for a “better” body is one that many of us are on, especially this time of year when beach days, pool parties and weddings crowd our calendars. Though our culture places cumbrous and often unrealistic expectations around physique (especially for women), there’s nothing abnormal about wanting to shed a few pounds or make other changes that we think can improve our appearance; but there is a line that can be crossed.

It’s one thing to stand before the mirror once in a while and think you’d prefer a trimmer waistline; it’s another to stand before the mirror daily and mercilessly judge your body (or an aspect of it) as problematic to the point where it impacts how you function.

This is where things become not normal, and may be indicative of Body Dysmorphic Disorder (BDD) — a condition that is far more common than you may think.

Obsessing over and trying to ‘fix’ a small or non-existent flaw

“BDD impacts anywhere from 5 to 7 million Americans,” says Catherine Silver, a licensed clinical social worker specializing in the treatment of eating disorders and body image issues. “BDD is characterized by an obsession with a perceived flaw or defect on one’s body. This perceived flaw is either non-existent to minor and is typically focused on a specific body part or area such as the size of someone’s nose, a certain patch of skin, their hair or a scar.”

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“There are usually compulsive behaviors in an attempt to ‘fix’ or hide the perceived flaw, including excessive mirror-checking, skin-picking or elaborate grooming rituals,” Silver says. “These obsessions and ritualistic behaviors ultimately get in the way of the person’s life and the person struggles to focus on other things aside from their perceived flaw.”

The flaw has to be slight or non-existent

But what about a so-called real flaw? For instance, let’s say you have teeth that are extremely crooked such that your dentist has suggested braces or implants and you’re frequently agonizing over their appearance. Do you have BDD? Based on this information alone the answer is no.

“The dysmorphia component of BDD precludes someone who actually has the flaw as they see it,” Dr. Carla Marie Manly, a clinical psychologist, tells NBC News BETTER. “Dysmorphia [presents] an inability to see thing correctly, If you [are obsessing over] a nose twice as large as a normal nose, or a BMI 30 pounds over, then you are no longer dysmorphic; by definition, the flaw has to be slight or non-existent.”

Dr. Kate Craigen, clinical director of binge eating and bariatric support services at Walden Behavioral Care points to the DSM-5 to sum up the main symptoms of BDD:

Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others

Repetitive behaviors (mirror-checking, reassurance-seeking from others) or mental acts (comparing appearance to others) in response to the appearance concerns

The concerns cause significant distress or impairment in social, occupational, or other areas of functioning

The concerns are not better explained by an eating disorder diagnosis

BDD doesn’t mean you hate your body, per se

The severity of your disdain for whatever perceived flaw really depends, and you don’t have to think your body (or an aspect of it) is absolutely grotesque in order to have BDD.

“People with BDD may describe the area of preoccupation on a spectrum of looking ‘not quite right’ to ‘hideous and disgusting,’” Dr. Craigen explains.

BDD affects men and women almost equally

BDD can be about any part of your body, and contrary to what some may have assumed (myself included) perceived fat or flab is only one of many types of BDD fixation. Additionally, BDD affects men and women almost equally.

“Current estimates suggest that 2.5 percent of American females and 2.2 percent of American males struggle with BDD,” says Dr. Craigen. “Those prevalence rates are higher in settings that are focused on changing something about appearance, such as the plastic surgeon’s office, the dermatologist’s office or at the orthodontist.”

Dr. Manly adds that she’s seeing more and more men struggling with BDD.

“Just [recently] I was working with a client who is so disgusted by his ‘small, horrible paws’ that he cannot bear to hold his wife’s hand,” Dr. Manly says. “You find a lot with men, especially as they age developing BDD around their breasts. Gynecomastia is enlarged breasts but when they do not qualify for that, when it is just skin sagging, they will obsess over it and not wear certain clothes, etc. Some men simply have rounder bodies that way and everyone has breasts, yet increasingly I’m seeing men [inflating this perceived flaw] and really focusing on it.”

Dr. Craigen adds that one form of BDD, muscle dysmorphia (the preoccupation with the idea that one’s body is too small or not muscular enough), occurs much more often in men.

Emotional breakdowns and a crippling fear of being seen

Isobel O’Hare, a poet, essayist and the author of “All This Can Be Yours,” first experienced BDD around the time she hit puberty, long after being diagnosed with OCD.

“My OCD manifested when I was very young, with my earliest memory of it from around 5 or 6 years old, while my BDD got severe at 13 or 14,” says O’Hare. “I would get up three hours earlier than I needed to and try on everything I owned — over and over again at times. I was obsessed with symmetry. I would part my hair perfectly down the middle and braid it on each side and if it was not symmetrical I would have an emotional meltdown. My mom was so wonderful and understanding, but I think this blindsided her because she didn’t understand what was happening. I would be sobbing in the morning because I felt I looked disgusting — like a huge, monstrous giraffe — and I missed a lot of school [as a result].”

BDD is closely tied to OCD

O’Hare’s experience with BDD in comorbidity with OCD is quite common — even more so than the comorbidity of BDD with eating disorders.

“BDD is included in the DSM-5 under the section, ‘Obsessive – Compulsive and Related Disorders’ which also includes hoarding disorder, trichotillomania (hair pulling) and excoriation (skin picking) rather than the ‘Feeding and Eating Disorders’ section where diagnoses like anorexia and bulimia are located,” notes Bethany Kregiel, a clinician at Walden Behavioral Care residential program.

Dr. Craigen adds that while eating disorders can occur in relation to BDD, and that some people meet the criteria for both, “the more common disorders are OCD and related disorders, and you are at higher risk for developing BDD if you have a first degree relative with OCD.”

BDD is treatable

If you think you have BDD or any other disorder, the first thing you should do is consult a licensed mental health professional.

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“Do not self-diagnose by researching online,” advises Dr. Manly. “A diagnosis is only helpful in allowing someone to understand what is going on and then seek treatment. Most medical practitioners and family doctors are not as well-versed in this area, simply because it’s not their specialty, so seek a psychologist or psychiatrist.”

Your psychologist will typically want to assess you for possible OCD and eating disorders. If you are diagnosed with BDD, know that it is highly treatable.

“A common way to treat are BDD is with cognitive behavioral therapy (CBT), of which I am a big fan,” says Dr. Manly. “You may also be prescribed medication such as SSRIs, but I don’t recommend using medication without [therapy] because it doesn’t address the underlying issue. I am also a big fan of support groups and traditional psychotherapy.”

‘Mindfulness reality checks’ can also help

“When I was 20 I started meditating and doing Buddhist techniques of mindfulness,” says O’Hare, who followed a four-step process. “It’s about recognizing the thought, identifying it, recognizing where it comes from and changing your reaction to it. It’s a kind of mindfulness reality check of ‘okay this is a feeling that is making me uncomfortable’ and recognizing that it’s coming from my brain, not reality and changing my response to it.”

O’Hare also turned to literature for guidance, and strongly recommends the books “Brain Lock: Free Yourself from Obsessive-Compulsive Behavior” by Jeffrey M. Schwartz and “Passing for Normal: A Memoir of Compulsion” by Amy S. Wilensky.

“Some days I really don’t appreciate what I look like,” says O’Hare. “But most days I do. I feel like a perfectly composed human being.”